Acupoint Catgut Embedding for Treatment of Chronic Pelvic Pain Due to the Sequelae of Pelvic Inflammatory Disease

Podsumowanie

This article outlines acupoint catgut embedding therapy for chronic pelvic pain caused by the sequelae of pelvic inflammatory diseases.

Streszczenie

Chronic pelvic pain caused by the sequelae of inflammatory pelvic disease is a common clinical condition of pelvic pain in women. At present, the main challenges in its treatment are the limited effectiveness of pain relief and the frequent recurrence of symptoms, which significantly impact patients' quality of life and impose a considerable psychological burden on them. It is a clinically challenging disease. After summarizing years of treatment experience, the author's team discovered that acupoint catgut embedding demonstrated notable clinical efficacy in managing chronic pelvic pain stemming from pelvic inflammatory disease sequelae. Compared to existing Western medicine treatment methods, acupoint catgut embedding offers advantages such as a good analgesic effect, lower recurrence rate, economic benefits, and a relatively straightforward procedure. This article provides a comprehensive guide on embedding absorbable catgut into patients' acupoints for the treatment of chronic pelvic pain in females resulting from the sequelae of pelvic inflammatory disease.

Wprowadzenie

Chronic pelvic pain (CPP) refers to pelvic pain that persists for over 6 months, is non-periodic, and is unresponsive to non-opioid drugs. The latest research shows that the global incidence rate of CPP is ~5%-26%¹. Sequential pelvic inflammatory disease (SPID) is one of the main conditions causing CPP, accounting for 23%-30% of all cases of chronic pelvic pain in females². Due to the limited efficacy of existing analgesics in alleviating this pain, over 50% of CPP patients may seek non-pharmacological treatment³. Currently, the main non-pharmacological treatments include pelvic floor physical therapy, psychological therapy, neuroregulation, and dietotherapy. However, they also have limitations, such as suboptimal pain relief and difficulties in achieving long-term control. Most SPID women with CPP experience anxiety, depression, and decreased quality of life due to recurrent pain⁴. Therefore, finding an effective treatment method that can alleviate patients' pain symptoms has become a pressing clinical concern.

Acupuncture and moxibustion, two of the main external therapeutic methods in traditional Chinese medicine, have shown good efficacy in treating pain-related conditions and have been widely used in clinical practice, especially in the relief of chronic pain, where their effectiveness surpasses other non-pharmacological treatments for CPP^5,6. In a cross-sectional study on the treatment of CPP with traditional Chinese medicine, 7.63% of chronic pain patients were chosen to receive acupuncture and moxibustion treatment, resulting in excellent therapeutic outcomes⁷. The acupoint catgut embedding introduced in this article is an extension and development of acupuncture and moxibustion. It refers to a traditional Chinese medicine external treatment technique that uses specially designed disposable medical devices to implant absorbable catgut into corresponding acupoints, providing prolonged and continuous acupoint stimulation to achieve analgesic effect. The author's team has employed this technology to treat recurrent and incurable pelvic pain in women caused by SPID, yielding positive outcomes. It can be utilized either as a standalone treatment or as an important component of a comprehensive traditional Chinese medicine treatment plan or a combination of traditional Chinese and Western medicine. This article takes the most common traditional Chinese medicine syndrome (dampness heat stasis type) patients with SPID as an example to provide a detailed demonstration of the procedures for acupoint catgut embedding.

Protokół

All procedures of this study were conducted in accordance with clinical trial registration and have been approved by the Ethics Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (Filing No. 2021KL-004). All patients in this study provided informed consent to the investigators' use of data, images, and related video filming during the trial.

1. Preparation before operation

1. Set the inclusion criteria as follows: include patients meeting the diagnostic criteria for pelvic inflammatory disease in Western medicine^8,9 and the dampness heat stasis syndrome type in traditional Chinese medicine¹⁰, aged 20-25 years old.
2. Set the following exclusion criteria: other causes of pelvic pain or lower abdominal pain; pregnancy, lactation, or preparing for pregnancy within the past 6 months; severe conditions affecting the heart, liver, kidneys, and hematopoietic system that make treatment intolerable; inability or unwillingness to cooperate; individuals prone to allergies or keloid formation; history of similar medication or physical treatments within the last month.
3. Get the following materials ready: sterile gloves, disposable catgut embedding needles, disposable thread embedding kit (treatment tray, sterile gauze, sterile cotton swab, iodophor cotton swab, tweezers, "0" catgut, medical patches; Figure 1).
4. Ask the patient to lie on her back, relax, and fully expose the abdomen and lower limbs.
5. Check the skin condition of the target acupoint location and proceed with the procedure if there are no abnormalities.
   NOTE: Patients with infection, ulceration, or scars on the skin at the acupoint should not undergo the embedding. Patients should not have the procedure right away if they are extremely hungry, fatigued, or under significant mental stress. Avoid performing the procedure on a menstruating patient.
6. Have the physician perform routine hand disinfection and wear sterile gloves.
7. Check whether the core of the disposable thread embedding needle and the needle tube match smoothly (Figure 2A).
8. Holding tweezers in the right hand, place the catgut into the needle tube (Figure 2B).
   NOTE: The catgut needs to be completely inserted into the needle tube.

2. Operating steps

1. Select the following acupoints (international code): Zhongji (RN3), Guanyuan (RN4), Qihai (RN6), Guilai (ST29), Zigong (EX-CA1), Xueha (SP10), Zusanl (ST36), Yinlingquan (SP9), and Sanyinjiao (SP6; Figure 3).
2. Needle insertion
   1. Tighten the skin of the needle insertion site with the left hand, and pinch the needle tube with the thumb, index, and middle fingers of the right hand.
   2. Quickly insert the needle downwards at a 90° angle to the skin (Figure 2C,D).
   3. When the patient experiences getting qi (needle sensation) such as soreness, numbness, and bloating, stop inserting the needle, push the needle core, and withdraw the needle tube, leaving the catgut in the qi-receiving area.
3. Needle extraction: Press the skin of the acupoint with the left hand and pull out the needle core and barrel with the right hand.
   NOTE: The catgut thread must be fully intradermal and should not be left subcutaneous or exposed outside the hypodermic.
4. Compress the needle hole with a sterilized dry cotton ball for 30 s and apply a medical application to the needle hole for 2 days.

3. Precautions after embedding the catgut

1. Ensure that the embedded site does not come into contact with water within the first 48 h.
2. Advise the patient to avoid strenuous physical activities, especially around the area where the thread was embedded, for 7 days following the procedure.

4. Adverse reactions and management

1. Patient discomfort
   1. Pain
      1. Advise patients that pain is a common adverse reaction¹¹ and that their pain will mostly disappear after 5-7 days.
      2. Use fine thread-embedding needles and catgut bodies during the procedure.
      3. Consider preoperative oral analgesics for patients who are sensitive to pain and have no known contraindications¹¹; If necessary, administer local anesthesia with lidocaine before embedding the catgut¹².
   2. Needle-related fainting
      NOTE: This refers to the sudden occurrence of dizziness, blurred vision, palpitations, nausea, and even syncope during the acupoint catgut-embedding treatment.
      1. If the patient faints, immediately stop the catgut embedding and observe the patient's vital signs. For milder cases, ask the patient to lie down for a while and receive warm water or a sugary drink. In cases where there is no alleviation of the symptoms, employ modern first-aid measures.
   3. Bleeding or local hematoma
      1. If postoperative bleeding occurs at the embedding site, apply gentle pressure with a dry cotton swab at the local site to stop it.
      2. If a hematoma forms, apply a cold compress within 24 h, followed by warm compresses after 24 h to promote hematoma absorption.
         NOTE: If the bleeding persists or is substantial, it may indicate vascular damage, necessitating surgical intervention.
2. Catgut body rejection reaction
   1. Fever
      NOTE: Any fever generally disappears within 1 week.
      1. Instruct the patients to drink plenty of water. Treat continuous fever with physical cooling or oral antipyretic medications.
      2. When prolonged high fever occurs, ensure prompt cooling and removal of the embedded catgut by a surgical specialist.
   2. Allergic reactions
      1. Look for allergic symptoms such as local redness, rash, and itching; provide antihistamine drugs (such as chlorpheniramine maleate, cetirizine, loratadine) or corticosteroids (such as dexamethasone) for allergy management, and if necessary, remove the embedded catgut from the body.
   3. Nodules or masses
      1. Small nodules usually resolve on their own. For localized firm masses, employ methods like moxibustion and acupoint injections¹³.
   4. Thread overflow
      1. Manage thread overflow by trimming or extracting the extruded catgut and then re-embedding it.
   5. Infection
      1. During the first 5 days after catgut embedding, there may be varying degrees of inflammation at the local site. If there is excessive discharge at the embedding site or signs of purulent changes, treat with antibiotics for infection control. If necessary, seek surgical intervention.

5. Observation indicators

1. Clinical efficacy evaluation¹⁴
   1. Define recovery as the improvement of all related symptoms and signs such as pelvic pain, with a score decrease of ≥95%.
   2. Define a significant effect as 70% ≤ score reduction < 95%.
   3. Consider the treatment to be effective if 30% ≤ score reduction < 70%.
   4. Consider the treatment to be invalid if the score reduction is <30%.
2. Use the simplified McGill Pain Scale (SF-MPQ)¹⁵ to evaluate pain emotions and severity before and after treatment, with higher scores indicating more severe pain.
3. Use the Traditional Chinese Medicine Damp Heat Stasis Syndrome Scale to score Traditional Chinese Medicine Syndrome¹⁶. The higher the score, the more severe the symptoms.
4. Evaluate abdominal tenderness or rebound pain, uterine tenderness, neck elevation and swing pain, and accessory tenderness before and after treatment using the Pelvic Physical Signs Scale¹⁷. The higher the score, the more severe the pelvic pain.
5. Use the World Health Organization quality of life (WHOQOL) - BREF scale¹⁸ to rate the quality of survival of the patients, and count the domain scores positively, meaning that the higher the score, the better the quality of life.

6. Statistical analysis

1. Express measurement data conforming to a normal distribution as mean ± standard deviation (SD).
2. Use an independent samples t-test for group comparisons and a paired samples t-test for comparisons before and after treatment.
3. Express data not conforming to a normal distribution as M (25%,75%).
4. Conduct group comparisons using the rank-sum test and comparisons before and after treatment using the paired rank-sum test.
5. Express counts or ordinal data as component ratios.
6. Perform group comparisons using Fisher's exact probability method or the Chi-square test.
7. Use a paired-design t-test for pre and post control. Perform bilateral hypothesis testing to α= 0.05; consider P < 0.05 to be statistically significant.

Wyniki

In this clinical study, a total of 88 participants were initially enrolled, with 8 cases dropping out (4 from the treatment group and 4 from the other one). The remaining 80 participants were divided using a random number table into the treatment and control groups, with 40 participants in each group. The course of treatment included catgut embedding once every 10 days, avoiding menstrual periods, for a continuous duration of 3 months. The patients in the treatment group also took a dose of Traditional Chinese Medicine d...

Dyskusje

There is no record of chronic pelvic pain in ancient Chinese medicine books, and according to its symptom characteristics, it can be mutually referenced with diseases such as "abdominal pain," "women's abdominal pain," and "menstrual abdominal pain." According to traditional Chinese medicine theory, when the blood vessels are open, improper care may lead to the invasion of pathogenic factors, such as dampness and evil heat, which can stagnate in the uterus and its channels, leading to a strugg...

Materiały

Name	Company	Catalog Number	Comments
disposable catgut embedding needles	Yangzhou Junbang Technology Development Co., Ltd	20212200112
disposable thread embedding kit	Shangdong Weigao Ruixin Medical Technology Co.,Ltd.	20182140148
SPSS26.0			statistical analysis software
sterile gloves	Fitone Latex Products Co.,Ltd Guangdong.	20172140158